Citation Nr: 18159359 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-58 629A DATE: December 18, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and adjustment disorder with depressed mood, to include as secondary to service connected residuals of prostate cancer, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1963 to December 1965. The scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Thus, the Board has recharacterized the Veteran’s claim as entitlement to service connection for an acquired psychiatric disability, to include PTSD and adjustment disorder with depressed mood. Entitlement to service connection for an acquired psychiatric disability, to include PTSD and adjustment disorder with depressed mood, to include as secondary to service connected residuals of prostate cancer, is remanded. The Veteran asserts that his acquired psychiatric disability is the result of his active duty service in the Republic of Vietnam, or in the alternative, as secondary to his service-connected disabilities, to include prostate cancer. See December 2018 Informal Hearing Presentation. The Veteran is the recipient of the Combat Infantryman Badge, and has combat experienced during service in the Vietnam War. The Veteran underwent a VA examination in March 2014. The examiner indicated that the Veteran reported no stressful no traumatic experiences during his time in service. The Veteran reported confrontational dreams related to past employment, sleep problems, depressed mood related to family and as a side effect of his prostate removal, and increased irritability. Upon examination, the examiner opined that the Veteran did not meet the criteria for a PTSD diagnosis, but did meet the criteria for a diagnosis of an adjustment disorder with depressed mood. She opined that the Veteran’s adjustment disorder was less likely as not caused by or a result of stressors experienced in service. The examiner did not offer an opinion as to whether the Veteran’s acquired psychiatric disability was secondary to his service-connected residuals of prostate cancer. In November 2014, the Veteran submitted private medical opinions from Dr. C.D. and Dr. S.E., who both suggested the Veteran as PTSD related to his service in Vietnam. Neither examiner provided a clinical explanation or rationale in support of their opinions. On remand, the Veteran should be requested to fill out a Statement in Support of Claim for PTSD and return it to VA. Upon receipt of that statement, the Veteran should be scheduled for a VA psychiatric examination to clarify his diagnoses, and to provide opinions addressing each of the Veteran’s contentions. The matter is REMANDED for the following action: 1. Send the Veteran a letter requesting that he fill out and return a Statement in Support of Claim for PTSD. 2. Then, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disability. The examiner should review the record, and take a history from the Veteran as to the progression of his disabilities. It should be noted that the Veteran is the recipient of the Combat Infantryman Badge based on combat participation during the Vietnam War. Upon review of the file, interview and examination of the Veteran, the examiner should respond to each of the following: a) Please clarify all current psychiatric disabilities. If PTSD is diagnosed, please identify the stressors upon which it is based. If PTSD is not diagnosed, please reconcile this finding with the statements of Dr. C.D. and Dr. S.E., who both indicate the presence of PTSD in their respective letters. b) For any disability identified other than PTSD, is it at least as likely as not (50 percent or greater probability) that such had onset in, or is otherwise related to the Veteran’s period of active duty service, to include his combat experiences in Vietnam? c) Notwithstanding the above, it is at least as likely as not that any diagnosed psychiatric disability is caused or aggravated beyond its natural progression by the Veteran’s service-connected disabilities, to specifically include his heart disease, residuals of prostate cancer, hearing loss, or erectile dysfunction? All opinion should be supported with a medical explanation. 3. Readjudicate the appeal. If the benefit sought is denied, send the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Bristow Williams, Associate Counsel